More than 90% of the diagnosed TB patients are successfully completing treatment in Nepal today. Nepal's anti-TB programme has received appreciation in the south-east Asian region which is the result of ongoing government commitment, community support, forging wide range of partnerships, and the use of innovative ways of ensuring access to Directly Observed Treatment Shortcourse (DOTS) - especially in remote areas, says Dr. Dirgh Singh Bam, Secretary, Ministry of Health, Nepal, who is also the former Vice-President of Nepal's Anti-Tuberculosis Association (NATA).

However it is due to poor programme performance of DOTS that ups the drug-resistant forms of TB including the multi drug-resistant TB (MDR TB). Up to 1.8% of new TB infections in Nepal, are of MDR-TB, informs Dr Bam.

MDR-TB is resistant to at least two of the best anti-TB drugs, isoniazid and rifampicin. These drugs are considered first-line drugs and are used to treat all persons with TB disease. Resistance to anti-TB drugs can occur when these drugs are misused or mismanaged. Examples include when patients do not complete their full course of treatment; when health-care providers prescribe the wrong treatment, the wrong dose, or length of time for taking the drugs; when the supply of drugs is not always available; or when the drugs are of poor quality, says Dr Bam.

Nepal reports up to 29% TB-HIV co-infection, says Dr Bam. He also talks about the TB and HIV co-infection, particularly among the injecting drug users (IDU). It is difficult to reach out to the IDU community to deliver healthcare services and need to work in partnerships is clearly critical. "Without addressing HIV and IDU issues, it will be very difficult to effectively respond to TB" says Dr Bam. People who use injecting drugs, and co-infected with HIV/TB, are also at increased risk of Hepatitis C (HCV) in Nepal.

Hepatitis C is a blood-borne, infectious, viral disease that is caused by the hepatitis C virus (HCV). The infection can cause liver inflammation that is often asymptomatic, but chronic hepatitis can lead to cirrhosis (scarring of the liver) and liver cancer. HCV transmission occurs when traces of blood from an infected person enter the body of a HCV-negative person. Like HIV, HCV is spread through sharing injection equipment, through needle stick or other sharps injuries, or less frequently from infected mothers to their babies.

HCV transmission rates are higher than that of HIV, and the condition is often more severe in drug users. People who share injection equipment are vulnerable to HCV and HIV infection, says Dr Bam. In Nepal, there is a separate health programme to respond to HCV, informs Dr Bam. However TB and HIV programmes in Nepal work much more collaboratively, says he.

"Community participation is very essential for effective TB/HIV care in Nepal" emphasizes Dr Bam. Patients who have successfully completed TB treatment were leading district level TB committees to improve TB programme performance in many instances in Nepal.

The Patients' Charter for Tuberculosis Care, outlines the rights and responsibilities of people with tuberculosis. It empowers people with the disease and their communities through this knowledge. Dr Bam feels if the Patients' Charter for Tuberculosis Care can be used as a tool to empower people with TB to be aware of their rights and responsibilities, then the TB programme performance will be improved furthermore.

Bobby Ramakant, who serves as The Seoul Times' Asia correspondent, is a member of NATT, Network for Accountability of Tobacco Transnationals, and edits Weekly MONiTOR series, reporting violations of tobacco control policies as a senior public health and development journalist. He writes for newspapers in 11 countries. He is the recepient of World Health Organization (WHO)'s Award for the year 2008. He can be reached at bobbyramakant@yahoo.com)